Society of Radiologists in Ultrasound Consensus on Routine Pelvic US for Endometriosis

Endometriosis is a prevalent and potentially debilitating condition that mostly affects individuals of reproductive age, and often has a substantial diagnostic delay. US is usually the first-line imaging modality used when patients report chronic pelvic pain or have issues of infertility, both common symptoms of endometriosis. Other than the visualization of an endometrioma, sonologists frequently do not appreciate endometriosis on routine transvaginal US images. Given a substantial body of literature describing techniques to depict endometriosis at US, the Society of Radiologists in Ultrasound convened a multidisciplinary panel of experts to make recommendations aimed at improving the screening process for endometriosis. The panel was composed of experts in the imaging and management of endometriosis, including radiologists, sonographers, gynecologists, reproductive endocrinologists, and minimally invasive gynecologic surgeons. A comprehensive literature review combined with a modified Delphi technique achieved a consensus. This statement defines the targeted screening population, describes techniques for augmenting pelvic US, establishes direct and indirect observations for endometriosis at US, creates an observational grading and reporting system, and makes recommendations for additional imaging and patient management. The panel recommends transvaginal US of the posterior compartment, observation of the relative positioning of the uterus and ovaries, and the uterine sliding sign maneuver to improve the detection of endometriosis. These additional techniques can be performed in 5 minutes or less and could ultimately decrease the delay of an endometriosis diagnosis in at-risk patients.

Roadmap to safety: a single center study of evidence-informed approach to placenta accreta spectrum

Objective

To assess the impact of an evidence-informed protocol for management of placenta accreta spectrum (PAS).

Methods

This was a retrospective cohort study of patients who underwent cesarean hysterectomy (c-hyst) for suspected PAS from 2012 to 2022 at a single tertiary care center. Perioperative outcomes were compared pre- and post-implementation of a standardized Multidisciplinary Approach to the Placenta Service (MAPS) protocol, which incorporates evidence-informed perioperative interventions including preoperative imaging and group case review. Intraoperatively, the MAPS protocol includes placement of ureteral stents, possible placental mapping with ultrasound, and uterine artery embolization by interventional radiology. Patients suspected to have PAS on prenatal imaging who underwent c-hyst were included in the analysis. Primary outcomes were intraoperative complications and postoperative complications. Secondary outcomes were blood loss, need for ICU, and length of stay. Proportions were compared using Fisher's exact test, and continuous variables were compared used t-tests and Mood's Median test.

Results

There were no differences in baseline demographics between the pre- (n = 38) and post-MAPS (n = 34) groups. The pre-MAPS group had more placenta previa (95% pre- vs. 74% post-MAPS, p = 0.013) and prior cesarean sections (2 prior pre- vs. 1 prior post-MAPS, p = 0.012). The post-MAPS group had more severe pathology (PAS Grade 3 8% pre- vs. 47% post-MAPS, p = 0.001). There were fewer intraoperative complications (39% pre- vs.3% post-MAPS, p < 0.001), postoperative complications (32% pre- vs.12% post-MAPS, p = 0.043), hemorrhages >1l (95% pre- vs.65% post-MAPS, p = 0.001), ICU admissions (59% pre- vs.35% post-MAPS, p = 0.04) and shorter hospital stays (10 days pre- vs.7 days post-MAPS, p = 0.02) in the post-MAPS compared to pre-MAPS patients. Neonatal length of stay was 8 days longer in the post-MAPS group (9 days pre- vs. 17 days post-MAPS, p = 0.03). Subgroup analyses demonstrated that ureteral stent placement and uterine artery embolization (UAE) may be important steps to reduce complications and ICU admissions. When comparing just those who underwent UAE, patients in the post-MAPS group experienced fewer hemorrhages greater five liters (EBL >5l 43% pre- vs.4% post-MAPS, p = 0.007).

Conclusion

An evidence-informed approach to management of PAS was associated with decreased complication rate, EBL >1l, ICU admission and length of hospitalization, particularly for patients with severe pathology.

Noninvasive prenatal screening and maternal malignancy: role of imaging

Noninvasive prenatal screening (NIPS) tests for fetal chromosomal anomalies through maternal blood sampling. It is becoming widely available and standard of care for pregnant women in many countries. It is performed in the first trimester of pregnancy, usually between 9 and 12 weeks. Fragments of fetal cell-free deoxyribonucleic acid (DNA) floating in maternal plasma are detected and analyzed by this test to assess for chromosomal aberrations. Similarly, maternal tumor-derived cell-free DNA (ctDNA) released from the tumor cells also circulates in the plasma. Hence, the presence of genomic anomalies originating from maternal tumor-derived DNA may be detected on the NIPS-based fetal risk assessment in pregnant patients. Presence of multiple aneuploidies or autosomal monosomies are the most commonly reported NIPS abnormalities detected with occult maternal malignancies. When such results are received, the search for an occult maternal malignancy begins, in which imaging plays a crucial role. The most commonly detected malignancies via NIPS are leukemia, lymphoma, breast and colon cancers. Ultrasound is a reasonable radiation-free modality for imaging during pregnancy, specially when there are localizing symptoms or findings, such as palpable lumps. While there are no consensus guidelines on the imaging evaluation for these patients, when there are no localizing symptoms or clinically palpable findings, whole body MRI is recommended as the radiation-free modality of choice to search for an occult malignancy. Based on clinical symptoms, practice patterns, and available resources, breast ultrasound, chest radiographs, and targeted ultrasound evaluations can also be performed initially or as a follow-up for MRI findings. CT is reserved for exceptional circumstances due to its higher radiation dose. This article intends to increase awareness of this rare but stressful clinical scenario and guide imaging evaluation for occult malignancy detected via NIPS during pregnancy.

Ovarian cancer reporting lexicon for computed tomography (CT) and magnetic resonance (MR) imaging developed by the SAR Uterine and Ovarian Cancer Disease-Focused Panel and the ESUR Female Pelvic Imaging Working Group

OBJECTIVES

Imaging evaluation is an essential part of treatment planning for patients with ovarian cancer. Variation in the terminology used for describing ovarian cancer on computed tomography (CT) and magnetic resonance (MR) imaging can lead to ambiguity and inconsistency in clinical radiology reports. The aim of this collaborative project between Society of Abdominal Radiology (SAR) Uterine and Ovarian Cancer (UOC) Disease-focused Panel (DFP) and the European Society of Uroradiology (ESUR) Female Pelvic Imaging (FPI) Working Group was to develop an ovarian cancer reporting lexicon for CT and MR imaging.

METHODS

Twenty-one members of the SAR UOC DFP and ESUR FPI working group, one radiology clinical fellow, and two gynecologic oncology surgeons formed the Ovarian Cancer Reporting Lexicon Committee. Two attending radiologist members of the committee prepared a preliminary list of imaging terms that was sent as an online survey to 173 radiologists and gynecologic oncologic physicians, of whom 67 responded to the survey. The committee reviewed these responses to create a final consensus list of lexicon terms.

RESULTS

An ovarian cancer reporting lexicon was created for CT and MR Imaging. This consensus-based lexicon has 6 major categories of terms: general, adnexal lesion-specific, peritoneal carcinomatosis-specific, lymph node-specific, metastatic disease -specific, and fluid-specific.

CONCLUSIONS

This lexicon for CT and MR imaging evaluation of ovarian cancer patients has the capacity to improve the clarity and consistency of reporting disease sites seen on imaging.

KEY POINTS

• This reporting lexicon for CT and MR imaging provides a list of consensus-based, standardized terms and definitions for reporting sites of ovarian cancer on imaging at initial diagnosis or follow-up. • Use of standardized terms and morphologic imaging descriptors can help improve interdisciplinary communication of disease extent and facilitate optimal patient management. • The radiologists should identify and communicate areas of disease, including difficult to resect or potentially unresectable disease that may limit the ability to achieve optimal resection.

Transvaginal Ultrasound-Guided Fine-Needle Aspiration Biopsy of Pelvic Lesions

OBJECTIVES

To assess adequacy of transvaginal ultrasound-guided fine-needle aspiration biopsy (TVUS-FNAB) for pathologic diagnosis of pelvic masses performed using onsite cytopathology consultation.

METHODS

In this Institutional Review Board approved, Health Insurance Portability and Accountability Act (HIPAA) compliant study, radiology records were retrospectively queried to identify patients who underwent TVUS-FNAB of a pelvic mass over a 11-year duration. TVUS-FNAB adequacy was determined by correlating cytopathology results with transvaginal ultrasound-guided core-needle biopsy (TVUS-CNB) or surgical pathology results when available, and with clinical diagnostic confidence when additional pathology confirmation was not available. Secondary analysis included patient age, history of hysterectomy, or pelvic malignancy. Target-specific features analyzed included mass size, depth, location, and final pathologic diagnosis.

RESULTS

Sixty patients underwent TVUS-FNAB of pelvic masses, 43 of which underwent FNAB only and 17 underwent both TVUS-FNAB and TVUS-CNB during the same procedure. TVUS-FNAB alone was adequate for diagnosis in 51 (85%) cases and addition of core-needle biopsy (CNB) achieved a diagnosis in additional 4 patients, increasing overall diagnostic accuracy to 92% (55/60). FNAB inadequacy had statistically significant association with increasing mass depth, occurrence of a minor intraprocedural complication, and decision to perform a CNB (P <.05). Number of FNAB passes, mass size, history of hysterectomy, and final diagnosis were not statistically significant predictors of FNAB adequacy.

CONCLUSION

TVUS-FNAB has a high specimen adequacy rate when performed with an onsite cytopathologist and can be considered first-line approach for image-guided sampling of pelvic lesions with option to add CNB if preliminary cytopathologic review does not confirm sample adequacy.

Differentiating complete hydatidiform mole and coexistent fetus and placental mesenchymal dysplasia: A series of 9 cases and review of the literature

•

Twin mole and placental mesenchymal dysplasia are set apart by patient symptoms, labs, and imaging.

•

Continuing with a twin mole pregnancy does not appear to increase the risk of GTN.

•

Twin mole pregnancy does carry an increased risk of miscarriage and pre-term labor.

To identify the differentiating features in clinical presentation, management, and maternal/fetal outcome in complete hydatidiform mole and coexistent fetus compared with placental mesenchymal dysplasia.

Between 1997 and 2015, five women with complete hydatidiform mole and coexistent fetus and four women with placental mesenchymal dysplasia were managed at the University of California San Francisco. Clinical features were analyzed and compared with previously published data.

Of the five cases of complete hydatidiform mole and coexistent fetus, two had live births. β-hCG levels were > 200,000 IU/L in all cases. On imaging, a clear plane between the cystic component and the placenta favored a diagnosis of complete hydatidiform mole and coexistent fetus. None of the patients went on to develop gestational trophoblastic neoplasia (GTN), with a range of follow-up from 2 to 38 months. Combining this data with previously published work, the live birth rate in these cases was 38.8%, the rate of persistent GTN was 36.2%, and the rate of persistent GTN in patients with reported live births was 27%. Of the four cases of placental mesenchymal dysplasia, all four had live births. One patient developed HELLP syndrome and intrauterine growth restriction; the remaining three were asymptomatic.

Maternal symptoms, fetal anomalies, β-hCG level, and placental growth pattern on imaging may help differentiate between complete hydatidiform mole and coexistent fetus and placental mesenchymal dysplasia. There was not an increased risk of gestational trophoblastic neoplasia in patients with complete hydatidiform mole and coexistent fetus who opted to continue with pregnancy.

ACR Appropriateness Criteria® Second and Third Trimester Screening for Fetal Anomaly

The Appropriateness Criteria for the imaging screening of second and third trimester fetuses for anomalies are presented for fetuses that are low risk, high risk, have had soft markers detected on ultrasound, and have had major anomalies detected on ultrasound. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Nuchal Translucency Evaluation at 11 to 14 Weeks of Gestation

A fetus with an increased nuchal translucency at 11 to 14 weeks gestation is at risk for aneuploidy, genetic syndromes, structural anomalies, and intrauterine fetal demise in both single and twin gestations. In addition to referral to genetics for counseling and consideration of diagnostic genetic testing, a detailed anatomic survey and fetal echocardiogram are indicated in the second trimester to screen for congenital malformations and major heart defects. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Second and Third Trimester Vaginal Bleeding

Vaginal bleeding can occur throughout pregnancy with varied etiologies. Although history and physical examination can identify many etiologies, imaging, in particular ultrasound (US), is the backbone of current medical practice. US pregnant uterus transabdominal, US pregnant uterus transvaginal, and US duplex Doppler velocimetry are usually appropriate for the evaluation of women with painless vaginal bleeding, those with painful vaginal bleeding, and also for those with second or third trimester vaginal bleeding with suspicion of or known placenta previa, low-lying placenta, or vasa previa. US cervix transperineal may be appropriate for those with painless or painful vaginal bleeding but is usually not appropriate for second or third trimester vaginal bleeding with suspicion of or known placenta previa, low-lying placenta, or vasa previa. Because the outcome of pregnancies is unequivocally related to the specific etiology of the vaginal bleeding, knowledge of imaging results directly informs patient management to optimize the outcome for mother and fetus. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Growth Disturbances-Risk of Fetal Growth Restriction

Fetal growth restriction, or an estimated fetal weight of less than the 10th percentile, is associated with adverse perinatal outcome. Optimizing management for obtaining the most favorable outcome for mother and fetus is largely based on detailed ultrasound findings. Identifying and performing those ultrasound procedures that are most associated with adverse outcome is necessary for proper patient management. Transabdominal ultrasound is the mainstay of initial management and assessment of fetal growth. For those fetuses that are identified as small for gestational age, assessment of fetal well-being with biophysical profile and Doppler velocimetry provide vital information for differentiating those fetuses that may be compromised and may require delivery and those that are well compensated. Delivery of the pregnancy is primarily based upon the gestational age of the pregnancy and the ultrasound findings. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

NTRK fusion cervical sarcoma: a report of three cases, emphasising morphological and immunohistochemical distinction from other uterine sarcomas, including adenosarcoma

AIMS

A unique fibrosarcoma-like tumour of the uterine cervix harbouring a rearrangement of a neurotrophic tyrosine kinase receptor (NTRK) gene (NTRK1 or NTRK3) has recently been described in 11 young women, some with recurrence and/or metastasis. The aims of this study were to expand the morphological spectrum of this tumour by reporting three additional cases that showed adenosarcoma-like features not previously described, one of which is the first reported to respond to targeted therapy, and to evaluate 19 conventional uterine adenosarcomas for evidence of NTRK rearrangement.

METHODS AND RESULTS

Three patients presented with a polyp or mass confined to the cervix. The constellation of polypoid growth, spindle cell morphology, entrapped endocervical glands and intraglandular stromal projections raised diagnostic consideration for adenosarcoma with stromal overgrowth. Deep cervical wall invasion was present in two cases at hysterectomy, and the third was removed by polypectomy. All three stained for S100 and pan-Trk, but were negative for a spectrum of other diagnostic markers. All three harboured NTRK rearrangements (TPM3-NTRK1, TPR-NTRK1, and SPECC1L-NTRK3). One patient developed pleural metastases at 16 months, received the NTRK inhibitor larotrectinib, and is free of disease 15 months later. Two others are alive without disease. None of the uterine adenosarcomas showed any S100 or pan-Trk staining, or rearrangement of NTRK1, NTRK2 or NTRK3 on next-generation sequencing.

CONCLUSIONS

Unusual adenosarcoma-like spindle cell neoplasms of the cervix may represent an NTRK fusion sarcoma, which can be detected by S100 and pan-Trk staining and confirmed by NTRK molecular testing. Conventional uterine adenosarcomas do not harbour NTRK rearrangements.

Endometriosis MRI lexicon: consensus statement from the society of abdominal radiology endometriosis disease-focused panel

Endometriosis is a common gynecologic disorder characterized by the presence of ectopic endometrial tissue outside the endometrial cavity. Magnetic Resonance Imaging (MRI) has become a mainstay for diagnosis and staging of this disease. In the literature, significant heterogeneity exists in the descriptions of imaging findings and anatomic sites of involvement. The Society of Abdominal Radiology's Endometriosis Disease-Focused Panel presents this consensus document to establish an MRI lexicon for endometriosis MRI evaluation and anatomic localization.

Recommendations for MRI technique in the evaluation of pelvic endometriosis: consensus statement from the Society of Abdominal Radiology endometriosis disease-focused panel

Endometriosis is a common entity causing chronic pain and infertility in women. The gold standard method for diagnosis is diagnostic laparoscopy, which is invasive and costly. MRI has shown promise in its ability to diagnose endometriosis and its efficacy for preoperative planning. The Society of Abdominal Radiology established a Disease-Focused Panel (DFP) to improve patient care for patients with endometriosis. In this article, the DFP performs a literature review and uses its own experience to provide technical recommendations on optimizing MRI Pelvis for the evaluation of endometriosis.

ACR Appropriateness Criteria® Assessment of Gravid Cervix

Preterm birth remains the leading cause of perinatal morbidity and mortality. Although the greatest risk factor for preterm birth is a history of prior preterm birth, a short cervical length (≤25 mm) before 24 weeks' gestational age is also associated with increased risk of spontaneous preterm delivery. As such, cervical length assessment has become of particular interest in predicting those patients at risk for preterm birth. Other clinical scenarios (eg, preterm labor, induction of labor, and active labor) may arise, in which assessment of the cervix may be of interest. Ultrasound is the mainstay imaging modality for assessing the gravid cervix, with transvaginal ultrasound recommended in patients at high risk for preterm birth or suspected preterm labor. Transperineal ultrasound is an alternate approach in those cases where transvaginal ultrasound in contraindicated. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Placenta Accreta Spectrum Disorder

Placenta accreta spectrum disorder (PASD) is the current terminology recommended by the International Federation of Obstetrics and Gynecology (FIGO) and should replace terms such as abnormally adherent/invasive placenta or morbidly adherent placenta. PASD refers to a variety of potential clinical complications, which may result from abnormal placental implantation. More specifically, placenta accreta refers to a defect in the decidua basalis where the chorionic villi adhere directly to the myometrium with trophoblastic invasion. Accurate antenatal diagnosis is needed to plan for an appropriate delivery strategy at an experienced center in order to reduce maternal and potential fetal morbidity and mortality. Obtaining radiologic and clinical data when PASD is first suspected can play a significant role in formulating an appropriate delivery strategy. Depending on the clinical risk factors and initial imaging findings, transabdominal ultrasound of the pregnant uterus with duplex Doppler and transvaginal ultrasound as needed are the most appropriate imaging procedures. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The development of a comprehensive multidisciplinary endometriosis and chronic pelvic pain center

Endometriosis affects 2%–10% of reproductive-aged women and is one of the leading causes of chronic pelvic pain. Given the extensive diagnostic challenges, multi-system nature of the disease, and significant impacts on quality of life, there has been a long-standing recognition of the need for integrated and specialty care for women living with endometriosis. We present our experience with the development of a multidisciplinary center for endometriosis and chronic pelvic pain at the University of California San Francisco. We describe the core components of this treatment model, including (1) methods for clinical collaboration across diagnostic, medical, and surgical subspecialties; (2) promotion of surgical excision of endometriosis; (3) establishment of a patient navigator; (4) utilization of psychological interventions and integrative medicine; and (5) health care provider and community training. Since the introduction of the endometriosis center in November 2016, outpatient encounters for patients with a primary diagnosis of endometriosis increased from 2761 in 2016 to 3905 in 2018, demonstrating high demand for these services. We also highlight opportunities for collaborative research through de-identified patient surveys, clinical data, and biospecimen collection.

Single institutional experience with initial ultrasound followed by computed tomography or magnetic resonance imaging for acute appendicitis in adults

PURPOSE

The objectives of this study was to assess the performance of ultrasound (US) for suspected appendicitis in adult patients and to evaluated the additive value of short-interval (within 1 week) computed tomography (CT) or Magnetic Resonance Imaging (MRI) after performing an initial US.

METHODS

In this IRB-approved, HIPAA-compliant, retrospective study, electronic medical records (EMRs) were queried for "US appendicitis" performed over a 2-year interval. EMR was reviewed for CT or MRI performed within 1 week of this exam, and if any new or additional information was available at subsequent exam. White count, patient disposition, and pathology, if surgery was performed, were also recorded.

RESULTS

682 patients underwent US for appendicitis over a 2-year duration, age range from 18 to 92 years (average: 30.1 years, M:F = 141:541). Findings showed 126/682 patients with normal appendix, 75/682 uncomplicated appendicitis, and 4/682 with complicated appendicitis. When performed, no additional findings were seen in these groups on short-interval CT or MRI. 2/682 patients had equivocal findings on US but eventually had normal appendix identified on CT. Four hundred and seventy-three patients had non-visualized appendix, of which only 14/473 (3.1%) eventually had appendicitis.

CONCLUSIONS

Ultrasound is an effective initial modality for evaluating appendicitis even in adult patients. Once a normal appendix, uncomplicated or complicated appendicitis is identified on US, no further imaging is necessary. Very few patients with non-visualization of the appendix eventually have appendicitis. Hence, these patients can be managed with active clinical follow-up rather than immediate CT or MRI. Symptoms and clinical scoring systems can be used for triage of these patients.

Placenta accreta spectrum: value of placental bulge as a sign of myometrial invasion on MR imaging

PURPOSE

To evaluate correlation of "placental bulge sign" with myometrial invasion in placenta accreta spectrum (PAS) disorders. Placental bulge is defined as deviation of external uterine contour from expected plane caused by abnormal outward bulge of placental tissue.

MATERIALS AND METHODS

In this IRB-approved, retrospective study, all patients undergoing MRI for PAS disorders between March 2014 and 2018 were included. Patients who delivered elsewhere were excluded. Imaging was reviewed by 2 independent readers. Surgical pathology from Cesarean hysterectomy or pathology of the delivered placenta was used as reference standard. Fisher's exact and kappa tests were used for statistical analysis.

RESULTS

Sixty-one patients underwent MRI for PAS disorders. Two excluded patients delivered elsewhere. Placental bulge was present in 32 of 34 cases with myometrial invasion [True positive 32/34 = 94% (95% CI 0.80-0.99)]. Placental bulge was absent in 24 of 25 cases of normal placenta or placenta accreta without myometrial invasion [True negative = 24/25, 96% (95% CI 80-99.8%)]. Positive and negative predictive values were 97% and 96%, respectively. Placental bulge in conjunction with other findings of PAS disorder was 100% indicative of myometrial invasion (p < 0.01). Kappa value of 0.87 signified excellent inter-reader concordance. In 1 false positive, placenta itself was normal but the bulge was present. Surgical pathology revealed markedly thinned, fibrotic myometrium without accreta. One false-negative case was imaged at 16 weeks and may have been imaged too early.

CONCLUSIONS

Placental bulge in conjunction with other findings of invasive placenta is 100% predictive of myometrial invasion. Using the bulge alone without other signs can lead to false-positive results.

Abdominal and pelvic imaging findings associated with sex hormone abnormalities

Hormones are substances that serve as chemical communication between cells. They are unique biological molecules that affect multiple organ systems and play a key role in maintaining homoeostasis. In this role, they are usually produced from a single organ and have defined target organs. However, hormones can affect non-target organs as well. As such, biochemical and hormonal abnormalities can be associated with anatomic changes in multiple target as well as non-target organs. Hormone-related changes may take the form of an organ parenchymal abnormality, benign neoplasm, or even malignancy. Given the multifocal action of hormones, the observed imaging findings may be remote from the site of production, and may actually be multi-organ in nature. Anatomic findings related to hormone level abnormalities and/or laboratory biomarker changes may be identified with imaging. The purpose of this image-rich review is to sensitize radiologists to imaging findings in the abdomen and pelvis that may occur in the context of hormone abnormalities, focusing primarily on sex hormones and their influence on these organs.

Risk of Malignant Ovarian Cancer Based on Ultrasonography Findings in a Large Unselected Population

IMPORTANCE

The risk of malignant ovarian cancer associated with simple cysts is unknown.

OBJECTIVE

To quantify the risk of ovarian cancer based on ultrasonographic characteristics of ovarian masses, including simple cysts, in a large unselected population.

DESIGN, SETTING, AND PARTICIPANTS

This was a nested case-control study of patients enrolled in Kaiser Permanente Washington, a large integrated health care system in Washington State. Participants were 72 093 women who underwent pelvic ultrasonography between January 1, 1997, and December 31, 2008. Analysis was completed in April 2017.

EXPOSURES

Ultrasonographic characteristics of ovarian masses measured in 1043 women, and also, using weights derived from the sampling strategy, estimated frequencies for the entire cohort.

MAIN OUTCOMES AND MEASURES

Malignant ovarian cancer, identified through December 31, 2011, by cancer registry linkage.

RESULTS

Among 210 women who were diagnosed as having ovarian cancer, 49 were younger than 50 years, and 161 were 50 years or older. Ultrasonography findings were predictive of cancer (C statistic, 0.89). The risk of cancer was significantly elevated in women with complex cysts or solid masses, with likelihood ratios relative to women with normal ovaries ranging from 8 to 74 and the 3-year risk of cancer ranging from 9 to 430 cases per 1000 women based on patient age and ultrasonography findings. In contrast, the 23.8% of women younger than 50 years and the 13.4% of women 50 years or older with simple cysts were not at a significantly increased risk of ovarian cancer compared with women with normal ovaries. Likelihood ratios associated with the detection of a simple cyst were 0.00 in women younger than 50 years (no cancers were identified) and 0.10 (95% CI, 0.01-0.48) in women 50 years or older, and the absolute 3-year risk of cancer ranged from 0 to 0.5 cases per 1000 women.

CONCLUSIONS AND RELEVANCE

According to this study, the ultrasonographic appearance of ovarian masses is strongly associated with a woman's risk of ovarian cancer. Simple cysts are not associated with an increased risk of ovarian cancer, whereas complex cysts or solid masses are associated with a significantly increased risk of ovarian cancer.

ACR Appropriateness Criteria® Postmenopausal Subacute or Chronic Pelvic Pain

Pelvic pain is common in both reproductive age and postmenopausal women, and the major etiologies change throughout the life cycle. Chronic pain is defined as lasting for at least 6 months. There are many gastrointestinal and urinary disorders associated with chronic pain in this age group, which are not discussed in this guideline. Pain may be localized to the deep pelvis, with potential causes including pelvic congestion syndrome, intraperitoneal adhesions, hydrosalpinx, chronic inflammatory disease, or cervical stenosis. Ultrasound is the initial imaging modality of choice, while CT and MRI may be appropriate for further characterization of sonographic findings. Alternatively, pain may be localized to the vagina, vulva, or perineum, with potential causes including vaginal atrophy, vaginismus, vaginal or vulvar cysts, vulvodynia, or pelvic myofascial pain. Imaging is primarily indicated in context of an abnormal physical exam and ultrasound is the initial modality of choice, while MRI may be appropriate for further characterization in select cases. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Advanced ultrasound applications in the assessment of renal transplants: contrast-enhanced ultrasound, elastography, and B-flow

Ultrasound is routinely used as the first imaging exam for evaluation of renal transplants and can identify most major surgical complications and evaluate vascularity with color Doppler. Ultrasound is limited, however, in the detection of parenchymal disease processes and Doppler evaluation is also prone to technical errors. Multiple new ultrasound applications have been developed and are under ongoing investigation which could add additional diagnostic capability to the routine ultrasound exam with minimal additional time, cost, and patient risk. Contrast-enhanced ultrasound (CEUS) can be used off-label in the transplant kidney, and can assist in detection of infection, trauma, and vascular complications. CEUS also can demonstrate perfusion of the transplant assessed quantitatively with generation of time-intensity curves. Future directions of CEUS include monitoring treatment response and microbubble targeted medication delivery. Elastography is an ultrasound application that can detect changes in tissue elasticity, which is useful to diagnose diffuse parenchymal disease, such as fibrosis, otherwise unrecognizable with ultrasound. Elastography has been successfully applied in other organs including the liver, thyroid, and breast; however, it is still under development for use in the transplant kidney. Unique properties of the transplant kidney including its heterogeneity, anatomic location, and other technical factors present challenges in the development of reference standard measurements. Lastly, B-flow imaging is a flow application derived from B-mode. This application can show the true lumen size of a vessel which is useful to depict vascular anatomy and bypasses some of the pitfalls of color Doppler such as demonstration of slow flow.

Imaging findings of concealed intra-amniotic hemorrhage in the setting of placenta previa and placenta accreta spectrum disorder

Placental abruption is an important cause of feto-maternal hemorrhage, with significant impact on both fetal and maternal mortality. In most cases, it presents with abdominal pain and vaginal bleeding. However, vaginal bleeding may be absent with concealed intra-amniotic hemorrhage, as in cases with placenta previa, hence confounding this diagnosis. In such cases, imaging studies may be obtained to evaluate for abdominal pain in pregnancy; hence, radiologists should be aware of the ultrasound and magnetic resonance (MR) imaging appearance of intra-amniotic hemorrhage. This includes presence of markedly echogenic amniotic fluid on US. Hemorrhage signal intensity on MR imaging varies with the duration of bleeding. In acute to subacute cases, it will present as T1 isointense and T2 hypointense amniotic fluid. This case is the first report of MR imaging findings of acute concealed intra-amniotic hemorrhage.

ACR Appropriateness Criteria® Multiple Gestations

Women with twin or higher-order pregnancies will typically have more ultrasound examinations than women with a singleton pregnancy. Most women will have at minimum a first trimester scan, a nuchal translucency evaluation scan, fetal anatomy scan at 18 to 22 weeks, and one or more scans in the third trimester to evaluate growth. Multiple gestations are at higher risk for preterm delivery, congenital anomalies, fetal growth restriction, placenta previa, vasa previa, and velamentous cord insertion. Chorionicity and amnionicity should be determined as early as possible when a twin pregnancy is identified to permit triage of the monochorionic group into a closer surveillance model. Screening for congenital heart disease is warranted in monochorionic twins because they have an increased rate of congenital cardiac anomalies. In addition, monochorionic twins have a higher risk of developing cardiac abnormalities in later gestation related to right ventricular outflow obstruction, in particular the subgroups with twin-twin transfusion syndrome or selective intrauterine growth restriction. Monochorionic twins have unique complications including twin-to-twin transfusion syndrome, twin embolization syndrome, and acardius, or twin-reversed arterial perfusion sequence. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Multimodality imaging of placental masses: a pictorial review

Placental masses are uncommonly identified at the time of obstetric ultrasound evaluation. Understanding the pathologies presenting as placental masses is key for providing a differential diagnosis and guiding subsequent management, which may include additional imaging with magnetic resonance (MR) imaging. Potential benign entities include chorioangiomas and teratomas. Larger chorioangiomas can cause fetal cardiovascular issues from volume overload. Placental mesenchymal dysplasia has an association with fetal anomalies and detailed fetal evaluation should be performed when it is suspected. Identifying other cystic masses such as partial and complete moles is crucial to prevent erroneous pregnancy termination. This review addresses normal imaging appearance of the placenta on ultrasound and MR imaging and describes various trophoblastic and nontrophoblastic placental masses. Potential placental mass mimics including uterine contractions and thrombo-hematomas are also presented.

Transvaginal Ultrasound-Guided Biopsy of Deep Pelvic Masses: How We Do It

The purpose of this review is to discuss the rationale and indications for transvaginal ultrasound-guided biopsy. Transvaginal ultrasound-guided biopsy can be a helpful tool for diagnosis and treatment planning in the evaluation of pelvic masses, particularly when the anatomy precludes a transabdominal or posterior transgluteal percutaneous biopsy approach. A step-by-step summary of the technique with preprocedure and postprocedure considerations is included.

PROMISe trial: a pilot, randomized, placebo-controlled trial of magnetic resonance guided focused ultrasound for uterine fibroids

OBJECTIVE

To evaluate the feasibility of a full-scale placebo-controlled trial of magnetic resonance-guided focused ultrasound for fibroids (MRgFUS) and obtain estimates of safety and efficacy.

DESIGN

Pilot, randomized, placebo-controlled trial.

SETTING

University medical center.

PATIENT(S)

Premenopausal women with symptomatic uterine fibroids.

INTERVENTION(S)

Participants randomized in a 2:1 ratio to receive MRgFUS or placebo procedure.

MAIN OUTCOME MEASURE(S)

PRIMARY OUTCOME

change in fibroid symptoms from baseline to 4 and 12 weeks after treatment assessed by the Uterine Fibroid Symptom Quality of Life Questionnaire (UFS-QOL); secondary outcome: incidence of surgery or procedures for recurrent symptoms at 12 and 24 months.

RESULT(S)

Twenty women with a mean age of 44 years (±standard deviation 5.4 years) were enrolled, and 13 were randomly assigned to MRgFUS and 7 to placebo. Four weeks after treatment, all participants reported improvement in the UFS-QOL: a mean of 10 points in the MRgFUS group and 9 points in the placebo group (for difference in change between groups). By 12 weeks, the MRgFUS group had improved more than the placebo group (mean 31 points and 13 points, respectively). The mean fibroid volume decreased 18% in the MRgFUS group with no decrease in the placebo group at 12 weeks. Two years after MRgFUS, 4 of 12 women who had a follow-up evaluation (30%) had undergone another fibroid surgery or procedure.

CONCLUSION(S)

Women with fibroids were willing to enroll in a randomized, placebo-controlled trial of MRgFUS. A placebo effect may explain some of the improvement in fibroid-related symptoms observed in the first 12 weeks after MRgFUS.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01377519.

Value of Intraoperative Sonography in Pancreatic Surgery

The utility of intraoperative sonography for pancreatic disease has been well described for detection and evaluation of neoplastic and inflammatory pancreatic disease. Intraoperative sonography can help substantially reduce surgical time as well as decrease potential injury to tissues and major structures. Imaging with sonography literally at the point of care--the surgeon's scalpel--can precisely define the location of pancreatic lesions and their direct relationship with surrounding structures in real time during surgery. This article highlights our experience with intraoperative sonography at multiple institutional sites for both open and laparoscopic surgical procedures. We use intraoperative sonography for a wide range of pancreatic disease to provide accurate localization and staging of disease, provide guidance for enucleation of nonpalpable, nonvisible tumors, and in planning the most direct and least invasive surgical approach, avoiding injury to the pancreatic duct or other vital structures.

Impact of new society of radiologists in ultrasound early first-trimester diagnostic criteria for nonviable pregnancy

OBJECTIVES

New early first-trimester diagnostic criteria for nonviable pregnancy recommended by the Society of Radiologists in Ultrasound via a multispecialty consensus panel extended the diagnostic size criteria of crown-rump length from 5 to 7 mm for embryos without a heartbeat and mean sac diameter from 16 to 25 mm for "empty" sacs. Our study assessed the potential impact of the new criteria on the number of additional follow-up sonograms these changes would engender.

METHODS

A retrospective study of all first-trimester sonograms in women with first trimester bleeding from 1999 to 2008 was conducted. Everyone included in the study had a visible gestational sac in the uterus. There were no pregnancies of unknown location or ectopic pregnancies included in this study cohort. Pregnancy of unknown location was used to describe cases in which there were no signs of pregnancy inside or outside the uterus on transvaginal sonography despite a positive pregnancy test result. A total of 1013 patients met the inclusion criteria.

RESULTS

Seven hundred fifty-two patients (74%) had identifiable embryos, and 261 (26%) did not. Of those with an identifiable embryo, 286 (38%) had no detectable embryonic cardiac activity. The breakdown of crown-rump lengths in this group was as follows: 100 measuring less than 5 mm, 36 measuring 5 to 7 mm, and 150 measuring 7 mm or greater. The breakdown of mean sac diameters in those without a visible embryo was as follows: 120 measuring less than 16 mm, 90 measuring 16 to 25 mm, and 51 measuring 25 mm or greater.

CONCLUSIONS

When diagnosing a failed pregnancy, there can be no room for error. Only 126 of 1013 early pregnancies threatening to abort (12%) fell into the more conservative zones defined by the new compared to the former size criteria (crown-rump length, 5-7 mm; mean sac diameter, 16-25 mm). Therefore, the potential impact of the new guidelines on follow-up sonograms does not appear inordinate.

Pseudotumor of the distal common bile duct at endoscopic retrograde cholangiopancreatography

BACKGROUND

Prior studies have described a pseudocalculus appearance in the distal common bile duct as a normal variant at cholangiography. The objective of this study was to describe the occurrence of pseudotumor in the distal common bile duct at endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

Nine patients who underwent ERCP between May 2004 and July 2008 were identified as having a transient eccentric mural-based filling defect in the distal common bile duct. A single reader systematically reviewed all studies and recorded the imaging findings.

RESULTS

The mean diameter of the filling defect was 9 mm (range, 5 to 11). Eight patients had resolution of the filling defect during the same ERCP or on a subsequent ERCP, and in two of these patients the inferior border of the filling defect was not well visualized. The other patient underwent surgical resection of a presumed tumor with no evidence of malignancy on surgical pathology.

CONCLUSION

An eccentric mural-based filling defect in the distal common bile duct can be artifactual in nature and may reflect transient contraction of the sphincter of Oddi. Recognition of this pseudotumor may help avoid unnecessary surgery.

Magnetic resonance spectroscopic imaging of benign prostatic tissue: findings at 3.0 T compared to 1.5 T-initial experience

In a retrospective study of 71 voxels of benign peripheral zone tissue from 3 men who underwent endorectal magnetic resonance (MR) spectroscopic imaging of the prostate at both 1.5 and 3 T, 21 voxels that appeared more malignant at 3 T to either of two readers demonstrated significantly higher levels of choline and polyamines at 3 T compared to 1.5 T using a Wilcoxon ranked-sum test; awareness of this selective amplification of these metabolic signals at high field strength may help avoid overdiagnosis of prostate cancer.

CT and MRI of early intrauterine pregnancy

OBJECTIVE

The objective of this article is to describe the CT and MRI findings of early intrauterine pregnancy.

CONCLUSION

Early pregnancy should be considered when CT or MRI shows a fluid-filled cystlike structure in the uterus of a woman of reproductive age especially if there is a coexistent ovarian corpus luteum cyst.

Imaging malignant and apparent malignant transformation of benign gynaecological disease

Common benign gynaecological diseases, such as leiomyoma, adenomyosis, endometriosis, and mature teratoma, rarely undergo malignant transformation. Benign transformations that may mimic malignancy include benign metastasizing leiomyoma, massive ovarian oedema, decidualization of endometrioma, and rupture of mature teratoma. The aim of this review is to provide a contemporary overview of imaging findings in malignant and apparent malignant transformation of benign gynaecological disease.

Computed tomography findings mimicking appendicitis as a manifestation of colorectal cancer

The primary computed tomography (CT) signs of appendicitis can also be seen with other inflammatory or neoplastic processes. We report on two cases in which appendiceal dilatation and peri-appendiceal fluid or stranding were the dominant imaging manifestations of colorectal carcinoma in the ascending colon. This study highlights the need to closely examine the ascending colon in patients with a suspected CT diagnosis of acute appendicitis, since these findings may be secondary to an inconspicuous colorectal carcinoma.

Fetal tracheolaryngeal airway obstruction: prenatal evaluation by sonography and MRI

We reviewed the sonographic and MRI findings of tracheolaryngeal obstruction in the fetus. Conditions that can cause tracheolaryngeal obstruction include extrinsic causes such as lymphatic malformation, cervical teratoma and vascular rings and intrinsic causes such as congenital high airway obstruction syndrome (CHAOS). Accurate distinction of these conditions by sonography or MRI can help facilitate parental counseling and management, including the decision to utilize the ex utero intrapartum treatment (EXIT) procedure.

The equivocal appendix at CT: prevalence in a control population

The purpose of the study was to determine the prevalence of appendices with an equivocal appearance at computed tomography (CT) in a control population. We retrospectively identified a control population of 150 patients who underwent CT of the abdomen and pelvis for evaluation of hematuria (without abdominal pain, fever, or colonic disease). One reader measured the diameter of the appendix and noted if the appendix was either isodense in appearance or airless and fluid filled. Sixty-seven of 150 cases (44.6%) demonstrated appendiceal diameter greater than 6 mm. The appendix was collapsed or isodense in 34/150 cases (22.7%). Only ten of 150 or 6.6% of cases were isodense in combination with diameter greater than 6 mm, and none had diameter greater than 10 mm. Only one of 150 cases (0.67%) demonstrated airless fluid within the lumen, and the appendix measured less than 6 mm. While the diameter of the normal appendix is frequently greater than 6 mm, none measured greater than 10 mm in combination with ambiguous morphology. Furthermore, in the normal appendix, airless fluid filling the lumen is a rare appearance with a prevalence of less than 1%. While appendicitis could undoubtedly occur in an isodense appendix between 6 and 10 mm in diameter, such an appearance can occur in up to 6.6% of the normal population

Intrauterine umbilical cord hemorrhage with associated jejunal atresia captured by real-time ultrasound

The presence of unexplained umbilical cord ulceration and hemorrhage has been sporadically reported in fetuses with antenatally suggested intestinal atresia. This case report illustrates a patient with spontaneous intrauterine umbilical cord hemorrhage, captured by real-time ultrasonography, in the setting of jejunal atresia with volvulus of the distal jejunal segment.